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Virtual Care: Implementation, Innovation, and the Future of Telehealth

by Alex Lennox-Miller | August 18, 2021

Boston Medical Center’s Rose Solomon joins Senior Analyst Alex Lennox-Miller to talk about the issues that her organization has faced, and the challenges yet to come, when implementing virtual care in provider systems. Value-based contracts, data management, and population health as a whole have faced many hurdles in the wake of the pandemic, and care delivery itself has rapidly undergone a series of intense changes. Now, at BMC, like many other providers across the country and the world, healthcare administrators are looking to leverage new technologies and procedures to meet patient needs and make care delivery more efficient.

This interview comes on the heels of our recent report, Virtual Care Management: Solutions Enabling Omnichannel Care. If this topic is of interest to you or relevant to your organization, please sign up for updates at the above link.

Transcript of the video below:

Alex Lennox-Miller: [00:00:00] Welcome to the Chilmark Channel. Thanks for joining us again. My name is Alex Lennox-Miller. I’m a senior analyst here at Chilmark Research. We’ve got a fantastic guest today. But before I get to that, remember to like this video, subscribe to our channel to stay up to date on all the latest research and health care IT, and share some comments down below so we can get back to you and really engage.

Alex Lennox-Miller: [00:00:30] Boston Medical Center serves some of the most vulnerable population in New England. It’s the largest safety net hospital in the region. It’s a tier one emergency center and they offer some of the greatest services in the Boston area. Joining us today is Rose Solomon from BMC. She’s going to talk to us about some of the work they’ve done in virtual care and some of the things that were really essential in deploying and supporting those tools over the course of the 2020 pandemic. Rose, thanks for being with me.

Rose Solomon: [00:01:03] Thanks for having me.

Alex Lennox-Miller: [00:01:05] So just to start off, can you talk a little bit about your role, what you do in BMC?

Rose Solomon: [00:01:11] Sure. So I am the population health manager for our primary care clinic. We are one of the largest outpatient clinics in BMC. We do over 120,000 visits annually and we serve a patient panel of just over 40,000. So my job is mostly surrounding value-based contracts and data management. So I tend to manage the claims database and any of our outcomes measures. And then ultimately I’m responsible for our performance in our HCO and any other alternative payment model contracts.

Alex Lennox-Miller: [00:01:44] And those patient populations include a significant number of elderly patients, correct? Medicaid and low-income patients. And because you deal really heavily with value-based contracts, you’ve probably seen firsthand how important chronic care and chronic care management can be back to those patient populations and to the bottom line of the hospital.

Rose Solomon: [00:02:03] Absolutely. We’ve seen a very interesting shift since the Medicaid HCO came about in 2018, where we now have a significant portion of our patients in an alternative payment model, whereas before it was far heavier weighted on the fee for service model. So it’s been an interesting shift of how do we show these contracts that we are providing the great care that we do to these patients without totally disrupting what the providers do? Naturally.

Alex Lennox-Miller: [00:02:28] And it’s always a big, tough question with with the pandemic as it came on in 2020, what kinds of changes did you guys have to make to the to the patient population, to the provider activity and the types of care that you provide?

Rose Solomon: [00:02:43] So on March 16th, we got the word that we were going live with telehealth. And in the course of that week, we went from one hundred percent in-person down to four percent in-person visits. So we basically flip the switch overnight on telemedicine, which I think across the board rocked everyone’s world. I can imagine, and especially in a practice that is so large and we have, you know, 80 to 90 attendings and anywhere from 100 to 110 residents with us annually, it was wild.

Alex Lennox-Miller: [00:03:14] I can only imagine. Yeah, there’s a lot to do when you’re deploying any kind of virtual care solution, but especially when you’re doing it all of a sudden on short notice. What you guys did it pretty successfully. I would say. When you look at, when you listen to, the numbers that you’re talking about, you look at the reaction that patients and providers have had. What do you think—other than than buying the technology—what do you think were the key elements that had to be in place either already in the system or that you had to introduce as a system to support the use of telehealth both from patients and providers?

Rose Solomon: [00:03:51] That is a great question. You know, I think when we first started, everything was telephone based because we didn’t have the infrastructure for video yet. That came quickly. But I think that was one of those things where the first version of what you introduce isn’t always the greatest. It worked. It got us starting video visits. But, you know, we were using Zoom or Doximity and it was challenging for a lot of providers. And that kind of sparked our need to actually invest in a telehealth platform.

Alex Lennox-Miller: [00:04:19] Because BMC doesn’t have the resources that some of the bigger, more famous hospitals have. You guys have a real reputation of making do out of having the kind of culture both in leadership and in your provider population to really be kind of agile, make those swift changes. How much did that help and what do you see as the key elements of that that were most important?

Rose Solomon: [00:04:45] Yeah, I would say we definitely try to make do with what we have before investing in other resources, I’d say, where we can be pretty crafty and very creative with trying to take full advantage of what we have access to before we actually invest in something. Which is why, you know, when we were starting this telehealth journey, you know, we started with telephone, we attempted video on resources we already had and then ultimately made the decision to invest in a platform. The providers willingness to be flexible was paramount throughout this whole thing. You know, we totally flipped the way they practice medicine on its head in like, a day. And they rolled with it, they were patient, they were flexible and they provided constructive criticism and feedback that helped us actually make this sustainable in the long term, which was incredibly helpful.

Alex Lennox-Miller: [00:05:37] So time providers into that and having them really involved, not just after the fact, but really throughout, probably made a huge difference.

Rose Solomon: [00:05:45] Yeah. And I mean, at the end of the day, they’re the end users for one portion of it. Obviously, we need to take the patient’s perspective into consideration and make sure that we pick something that is easy to understand, easy to use. You know, it’s easy to adapt. We have some patients who have low reading literacy. So making sure that we can find something where we can customize the instructions and translate them into a number of languages. But, you know, the other component of that is the doctors have to be able to provide the care, and these providers need to be able to actually utilize this platform to interact successfully with their patients, so that they can provide services.

Alex Lennox-Miller: [00:06:19] I really want to dig into that question of what the patients need in order to have one of these platforms to be really successful, because you guys serve an incredibly diverse patient population, a really challenging patient population, as you started to have more and more use of telehealth. What were the biggest resource barriers that you guys saw, or that BMC saw, and how did you address them?

Rose Solomon: [00:06:46] Access to video has been difficult nowadays, actually. You know, a large portion of our patients do have access to smartphones, which is great, but not all of them have access to Internet that is fast enough to actually conduct a successful video visit. So there’s definitely a large gap in that regard, which, you know, is slightly concerning financially as a system, because telephone visits are reimbursed significantly lower than video visits. And, you know, eventually they may actually get rid of telephone reimbursement altogether. Everyone changes their mind on that one. So I’d say that was kind of the biggest gap that we’ve had to work with. And, you know, it’s it’s much harder to conduct a visit over the telephone when you’re just having a conversation and you can actually see the patient and see the body language, see how they react to something that you say. So the video component has been a challenge for us.

Alex Lennox-Miller: [00:07:37] As you look forward and potentially as those telephone reimbursements are reduced or eliminated, how do you think you’re going to be able to provide some of those services? Is this something where the infrastructure needs to be put in place in order for these patients to have access to this? Or is this something where potentially you could have some ability to supply at least a cellular connection or something like that?

Rose Solomon: [00:08:06] I think in the long term, that is a strategy that’s a little bit up in the air right now. You know, as a practice, we, you know, we provide primary care and not every single visit you need to be physically present with your doctor. So we’re trying to evaluate what’s the right mix of telemedicine to hold on to long term. You know, this pandemic brought about a shift that I think the health care system has been sort of putting off for a very long time. It happened overnight. So telemedicine, in my opinion, is here to stay. And now we just have to figure out clinically, how do we integrate that successfully into our into our practice and, you know, what is that right balance.

Rose Solomon: [00:08:41] So as a clinic, we’ve been doing a lot of shifting from telemedicine to in-person and trying to figure out what’s the right slot mix like, how many telemedicine appointments do we need to save? You know, like what is that balance? And then for things like chronic disease management, how do we integrate telemedicine into those programs where we are able to supply a hypertensive patient with a blood pressure cuff? Can they come in, in-person, get oriented to their cuff? We make a medication change, and then two weeks later they have a video visit with their provider so that they don’t have to come back in and they can just conduct a visit at home because they have those tools. So we’re trying to evaluate that now. And that’s a big old question mark.

Alex Lennox-Miller: [00:09:19] Yeah, I can imagine. And something that I, I would guess, you know, you can set up sort of general rules for conditions, but I would imagine you also need to leave some flexibility for providers to say, well, this patient need you know, hypertension is not all hypertension in this patient can do some remote visits, but this patient needs to come in in-person.

Rose Solomon: [00:09:41] Yeah. And, you know, I think what’s tricky is we have providers who are, you know, like 75 to 25 percent telemedicine. We have providers who are 100 percent in-person. You know, everyone’s schedules kind of changed with the pandemic in their child care changes. And we need to react to that and be flexible with them. We also have to figure out, like, how do we take care of these patients? So I think we’ve had to be a little bit more creative about, you know, like care teams and your team management. You know, if you are one hundred percent virtual, say, or you know what you’re in, it’s your telehealth week. But you have someone who used to come in person leveraging a colleague that’s on a care team, that you can have that patient come in and be seen in person. So I think it’s encouraged collaboration. But I think in a really good way.

Alex Lennox-Miller: [00:10:28] The collaborative aspect of it is one that I’ve always been fascinated by and what’s really interesting to me is the extent to which it’s not just provider collaboration, it’s collaboration with social workers, potentially it’s collaboration with members of the family or caregivers. How much would you say you guys are finding ways to leverage those people who aren’t necessarily doctors but still can play a really big role in bringing patients into these remote appointments?

Rose Solomon: [00:11:03] Yeah, so we have a pretty diverse team of of staff in the office that take care of these patients. So obviously, you’ve got your providers. We have patient navigators who are helping these patients navigate the health care space so they help with prior authorizations for testing. They help with follow up appointments. And they also do a lot of social navigation. So any time a patient screens positive for some sort of social support, one of the outcomes of that, if they get a visit with the patient navigator to actually connect them with the resources. So we try to make that connection face-to-face in person.

Rose Solomon: [00:11:40] You know, we have a wonderful team of medical assistants and front desk staff, and our nursing team is great. And everyone works together to surround that patient from every aspect and really try to provide them with the care that they need, adapting it to a partially virtual world that’s been challenging. And we had to get creative with our EMR and messaging systems of like, how does this work? You know, early on in the pandemic, we learned a lot. And we made a lot of changes.

Rose Solomon: [00:12:07] But what was really challenging was it actually drastically shifted the responsibilities of each of those teams. So, you know, like the front desk team went from checking in hundreds of patients a day to having you sit at the computer and answer a ton of messages about scheduling appointments instead of just interacting with the patient face-to-face. It was really difficult to help them manage their day to day because it was so drastically different. And so it took a while to kind of get everyone to adapt and to understand, this is my role in this virtual world. And now that we’re kind of like creeping back to in person, we’re going through a little bit of this shift again of, OK, we’ve got some of these patients who we need to support virtually, but we also have all these patients coming in, in person in our workforce has shifted a little bit.

Alex Lennox-Miller: [00:12:52] It’s interesting to see how so much of this has really forced some of those silos to break down and forced some of those organizational barriers or organizational boundaries to really shift, and hopefully for the best. I mean, it’s been something that health care has struggled with for a very long time. Do you see your success there as part of that sort of culture of BMC that that was another area where people were able to trust that these were the right things to do, that really helped in breaking these barriers down?

Rose Solomon: [00:13:32] That’s a great question. You know, I think in general, when administrators just make decisions on their own, they’re not super well received from the clinical side of the equation. So I think having everyone at the table to make these choices was really important for us to actually make this successful.

Alex Lennox-Miller: [00:13:51] You mentioned some of the social resources the BMC provides, and certainly in my experience, plus medical center, it was really early in recognizing the importance of social determinants of health, of the availability and access to these resources in long term care and chronic care, in supporting patients, staying home, keeping them out of hospitals, out of the ERs. BMC has created some really interesting resources for addiction, support for elderly nutrition and diet, care that aren’t directly clinical but still play a really important role. How much do you see those kinds of still virtual tools becoming part of your broader toolbox, so to speak? And what kind of role do you see for them in virtual care at home?

Rose Solomon: [00:14:47] Well, I think a lot of that depends on what successes we see from those programs. So, for example, one of our addiction treatment programs was actually wildly successful in a virtual model and connecting patients to medication, assisted therapy, their volumes kind of, you know, skyrocketed during the pandemic. And so when we’re able to connect with patients like that more successfully, you know, we are very willing to figure out how do we make that fit long term so that we’re able to meet those patients where they’re at. You know, that’s so much of what our social supports actually try to do is meet all of our patients where they’re at. So we can support them the way that they need to actually achieve health.

Rose Solomon: [00:15:29] And you know, it’s kind of similar to the new nutrition programs, right? If we are able to connect the X portion of our population with those services successfully, then we can consider that a win and would heavily consider continuing that. You know, sometimes we start projects like anyone does with the best of intentions. And when you execute, it doesn’t always work as you intended because it’s really an interesting space where, you know, people want to be there. People truly identify with the mission driven nation nature of the organization. And, you know, if you’re not willing to kind of go with the flow and be flexible, it’s likely not a great fit for you. And, you know, people tend to kind of self select.

Alex Lennox-Miller: [00:16:13] I mean, it’s something that we’ve seen a real cultural shift in some organizations in health care, that willingness to kind of adapt and try new things and change and others are really not. And I always get kind of concerned, looking at the cost of tools and the cost of software, that there are these almost potentially insurmountable barriers to smaller organizations or independent organizations to leverage this stuff. But when it comes to the culture and the ability to really implement them, well, it seems like more and more that’s where you see that ability to really shift and try new things and change.

Rose Solomon: [00:17:04] As we move forward and as we go from the real immediate needs of the pandemic into trying to find out and figure out what the future is going to look like. From your perspective as somebody dealing with CDC contracts with chronic care and primary care, what do you see as some of the most important opportunities coming up? Is it in remote patient monitoring? Is it in automation of care team tasks and care management? I’m curious what you see as the potential sort of the biggest potential difference maker.

Rose Solomon: [00:17:47] Yeah, you know, I think in an ideal world, everyone would love to start doing remote monitoring, but the costs of that from an infrastructure standpoint and a technology standpoint, I think are just a little outrageous. You know, I think if we could have our diabetic patients have a glucose monitor at home that Bluetooth in, that’ll be incredible. But realistically, probably not going to happen.

Rose Solomon: [00:18:16] You know, I think where the pandemic has really shifted our direction in primary care, at least, is it’s helped us recognize our need to really leverage our EMR more efficiently and more effectively. I think it really brought about from the provider perspective, at least from what I’ve heard anecdotally, you know, they don’t have all the information they need when they don’t have the clinics surrounding them. So how do we leverage the tools that we have better to help them with their practice? Well, as we’re navigating this new space, I think it’s more about leveraging again, you know, it’s more about leveraging what we have to its fullest extent and and trying to invest in our own I.T. solutions before we bring on another external.

Alex Lennox-Miller: [00:18:57] Finding ways to access the data, engage patients and present it, as opposed to trying to introduce something novel and new that may not, like you said, may not make the difference it needs to.

Rose Solomon: [00:19:10] Exactly. And, you know, even by changing how we leverage tools we already have, it’s going to introduce new processes and workflows. So, you know, there is a lot of change that comes about even utilizing what you have differently, but it’s slightly different and it’s more familiar than bringing on a new tool. So it usually gets us a little more buying up front up. Like here’s something you’re familiar with. We’re just going to teach you how to use it differently. And then we see how that goes.

Alex Lennox-Miller: [00:19:34] Something that that’s really directly within their workflow. As opposed to having to shift everything.

Rose Solomon: [00:19:40] Right. Plus, the more we can give them access to the tools they need in the space that they use. So the more we can leverage our EMR while they’re in it to give them that information, that better. So they’re not toggling between screens or between programs, it just makes their lives significantly easier.

Alex Lennox-Miller: [00:19:55] Yeah, and I imagine when it comes to buy in, when it comes to not just building, but sustaining that culture, those are really essential.

Rose Solomon: [00:20:03] Yeah, absolutely.

Alex Lennox-Miller: [00:20:06] Well, thank you so much for your perspective and thank you so much for talking. It’s great to see you. Yeah. And I hope we can continue the conversation in the future.

Rose Solomon: [00:20:15] Wonderful. Thank you for having me.

Alex Lennox-Miller: [00:20:17] Thank you so much for joining us. Please remember to like the video. Subscribe below and leave a comment. Me, Rose, or anyone else on the Chilmark team.

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